Localization of Atrial Fibrillation Triggers in Patients Undergoing Pulmonary Vein IsolationImportance of the Carina Region
Ermengol Valles, MD*, ,
Roger Fan, MD*,
Jean François Roux, MD*,
Christopher F. Liu, MD*,
John D. Harding, MD*,
Sandhya Dhruvakumar, MD*,
Mathew D. Hutchinson, MD*,
Michael Riley, MD*,
Rupa Bala, MD*,
Fermin C. Garcia, MD*,
David Lin, MD*,
Sanjay Dixit, MD*,
David J. Callans, MD*,
Edward P. Gerstenfeld, MD* and
Francis E. Marchlinski, MD*,*
* Electrophysiology Section, Cardiovascular Division, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Universitat Autònoma de Barcelona, Barcelona, Spain
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Figure 1 Internal View of the Right PVs From LAO Projection of an Electroanatomic Map Merged With Computerized Tomography
The distribution of the pulmonary vein (PV) segmentation is shown. Segments adjacent to carina in between right PVs and carina itself (CZ) are enhanced with a yellow shadow. Segments far from carina (NCZ) are enhanced with a blue shadow. A = anterior; CZ = carina zone; I = inferior; IA = inferior-anterior; IP = inferior-posterior; LAO = left anterior oblique; NCZ = noncarina zone; P = posterior; S = superior; SA = superior-anterior; SP = superior-posterior.
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Figure 2 Identification of Origin of PV Trigger
Panels A and B show surface electrocardiographic (ECG) tracing and recordings from circular mapping, ablation, coronary sinus, and posterior right atrium–superior vena cava catheters. Panel E is a detailed image from panel B, showing the activation sequence of the trigger inducing atrial fibrillation. Red arrows point to the earliest electrogram, which corresponds to bipole 7 to 8 of the circular catheter. Activation in the ablation catheter is almost as early as in the earliest bipole of the circular catheter. The blue arrow identifies the distal bipole of the coronary sinus catheter. Of note, there is bracketing in the activation sequence during the trigger beat, suggesting an origin in the left PVs. Panels C and D are right anterior oblique (RAO) and LAO fluoroscopic projections, respectively, showing the placement of the catheters during the initiation of the atrial fibrillation. The trigger arose from the superior-posterior segment of the left superior PV, corresponding to the location of bipole 7 to 8 of the circular mapping catheter. Abbreviations as in Figure 1.
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Figure 3 Schematic Representation of the Distribution of All Triggers From the PVs
Pulmonary vein ostia have been segmented and are shown in a coronal view. The carina zone is enhanced with a blue shadow. Dark blue dots correspond to carina zone triggers, and light blue dots correspond to noncarina zone triggers. The segments are indicated in the same fashion as Figure 1. LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein; RIPV = right inferior pulmonary vein; RSPV = right superior pulmonary vein; other abbreviations as in Figure 1.
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Figure 4 Identification of a Trigger Originating in the Superior-Posterior Segment of the Left Superior PV
Panels A and B show the fluoroscopic image in LAO and RAO projections, respectively, of the catheter location. The circular catheter is placed in the left superior PV ostium and the ablation catheter is placed at the right carina. Panel C shows recordings from circular and ablation catheters. The earliest electrogram is noted in bipole 6 to 7 of the circular catheter (red arrow). Panel D shows the detail of the circular catheter in the left superior PV ostium in RAO projection. One can identify the origin of the trigger from the superior-posterior segment of that ostium. If the earliest bipole was localized to the carina region, maneuvers to rule out origin in the left inferior PV, placing the ablation catheter in its ostium during the induction, were done. Abbreviations as in Figures 1 and 2.
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